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Enfoque inicial de la pareja infertil
- 1. EVALUACION BASICA DE LA PAREJA INFERTIL: MBE
- 3. SISTEMA DE GRADACION DE MBE A. Reportes primarios: 1. Clase A: RCT. 2. Clase B: estudio de cohortes. 3. Clase C: estudio caso control o con controles històricos. 4. Clase D: serie de casos, reporte de caso. B. Síntesis a partir de reportes primarios: 1. Clase M: Metaanàlisis, revisiones sistemàticas, análisis de decisiòn, anàlisis costo eficacia. 2. Clase R: Consensos , revisiones narrativas. 3. Clase X: Opinión mèdica.
- 4. TAMIZAJE INICIAL EVALUACION BASICA DISFUNCION OVULATORIA
- 6. Factor masculino? Factor anatòmico? Si No Si No TAMIZAJE INICIALEVALUACION BASICA DISFUNCION OVULATORIA HSG ANORMAL EVALUACION MASCULINA INICIAL
- 8. Pareja infértil Trab. inicial infertilidad: . HC y EF femenino y masculino. . Seminograma . Material educativo. .Consulta preconcepcional Mujer inmune: rubeola varicela Inmunizar contra rubeola o varicela Ver algorit de trab inicial de infertilidad masculina Ver algorit básico trab inicial de infertilidad Si No
- 9. II. EVALUACION BASICA DE LA PAREJA INFERTIL
- 10. Evaluar por Factores(M) Espermatog Normal?. Frecuencia rs. Disfunciones sexuales. Continuar evalución M y F Evaluar factores de la pareja No Si Algort infertil masculina Evaluar por Factores(F) Evaluar por Factores(F) Pagina siguiente
- 11. Evaluar por Factores(F) < 35 a. Evaluar historia Referir a especialista en infertilidad FSH y E2: día 3. Normal? No Si D.ovulatoria androgenizant? Disfunción ovulatoria? Factores anatòmicos? No Si Si Continúa Pagina siguiente Pagina siguiente Pagina siguiente
- 12. Algor de HSG anormal HSG Anormal? TSH, PRL, FSH y E2 Algor de disfunciòn ovulatoria Protocolo: androgenizaciòn U obesidad centrípeta Ovulación normal? No D.ovulatoria androgenizante? Disfunción ovulatoria? Factores anatòmicos? No Si Si HSG Laparoscopía o tto empìrico SiNo Si NoSi No
- 14. Evaluación disfunciòn ovulatoria Amenorrea?. Consultar con ginecòlogo famili con endocrinologia de la reproduc. para tto específico Referir a especialista en infertilidad: gonadotropinas o anàlogos GnRh Test progesterona No TSH,FSH,PRL, testosterona total, DHEAS normales? No Si Si Sangrado deprivaciòn Empezar utiiizando c. de clomifeno No No Si Pagina siguiente
- 15. Ver algor de anormal HSG Tto exitoso?. Considerar evaluación de fase lútea, HSG . No Si Si HSG normal? Continuar clomifeno x 3-6 m No Ver protocolo de Cuidado prenatal Considerar laparoscopía y/o alternativa inducción de ovulaciòn Continúa
- 16. IV. HSG ANORMAL
- 17. HSG anormal Es IVF opciòn?. No Si Pagina siguiente Categorizar resultados HSG Cavidad uterina anormal Trompas anormales Sospecha Sind. adherencial Repetir HSG/laparoscopia ambos con canulaciòn tubàrica Oclusiòn proximal Continuar eval infertilidad o considerar tto Qx Referir para Histeroscopia Operatoria(E) No permeabilidad y patologìa distal Es IVF una opción?. Refer a endoc Reprod (cons) Evaluación. pronòstica preoperatoria Evaluaciòn Cirug reprod Hidrosalpinx presente: IVF con salpinguectomìa o ligadura laparoscòpica Es oclusiòn bilateral?. Si No Si No
- 18. SA moderado leve?. Sospecha de Sindrome adherencial No Si SA severo? Retornar a apropiado protocolo Laparoscopìa dx y/o terapeùtica Retornar a apropiado protocolo Referir a endoc de la reprod para IVF No Si Adhesiólisis Continúa
- 20. Varòn se presenta para protocolo de infertil Síntomas infecciòn?. Historia SS semen. Semen Normal? No Si Pagina siguiente Exposicion Gonatoxin? Repetir ss Semen si no gestaciòn en 4m Semen normal? Algoritmo eval bàsica infertilidad Embarazo? Si oligoospermia: FSH,PRL,Test. Referir a especi (E) (E) Especialista: IUI,IVF U otras causas de Infertilidad mascu. No Repetir ss Semen C/3m x4 Si No Si No Si
- 21. Síntomas infecciòn?. Considerar tto empírico No Si 2do ex semen normal? Repetir anàlisis Semen en 1m 3er ex Semen normal? Algoritmo eval bàsica infertilidad Persiste infección? Si oligoospermia: FSH,PRL,Test. Referir a especi (E) NoRepetir análisis semen en 1m Si No Si No Embarazo? Si Referir a especial en infertilidad masc(E) (E) No Pagina anterior Si
- 22. RESUMEN
- 23. RESUMEN 1. Esta basado en evidencias. 2. El protocolo de evaluación básica de la pareja infertil esta dirigido a ginecòlogos no especialistas en infertilidad. 3. Es especìfico en indicar las limitaciones del ginecólogo. 4. Ubica los momentos oportunos en los que la paciente debe ser referida a un especialista. 5. Utiliza como punto de corte los 35 años. 6. Solo utiliza para inducción de la ovulaciòn el citrato de clomifeno. 7. La máxima complejidad a la que llega es la inseminaciòn intrauterina, la microcirugìa tubàrica y la laparoscopìa diagnóstica con cromotubaciòn y adhesiòlisis.
- 24. La ciencia es un ideal, la de hoy corrige a la de ayer y la de mañana corrige a la de hoy. Ortega y Gasset.
Notas del editor
- La historia escrita de la terapia de reemplazo hormonal se remonta a los años 1880 en que en RU un mèdico tomando extracto de testìculo piensa haber descubierto el elixir de la juventud. Propone que el mimsmo cambio podrìan lograr las mujeres si tomaran el extracto de ovario. Posteriormente se administra líquido amnìótico de vaca.
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R
- Initiation of an infertility evaluation should be undertaken after 12 menstrual cycles or one year RS, or after 6 menstrual cycles or 6 months of intercourse for 35. Evaluation could be considered earlier in situations with significant historical factors which could compromise fertility, such as irregular cycles, pelvic inflammatory disease (PID), or previous infertility. Supporting evidence is of class: R 3. Provide Couple with Education Materials and Refer to Appropriate Resources 4. Infertility Work-Up Supporting evidence is of class: R